Even Modest Weight Loss Helps Knee Pain

Do you have an overweight client who also has knee osteoarthritis? Here’s a bit of encouraging news that might bolster your efforts to help him lose weight and keep it off. According to research presented in November at the American College of Rheumatology Annual Scientific Meeting in Washington, DC, “very attainable” weight loss goals are enough to reduce pain.


Weight gain increases pounds of pressure and loading forces on the knee structure. Since extra pressure leads to more wear and tear over time, body weight is considered a significant contributor to the onset and progression of knee arthritis. While weight loss can help relieve the pain, clients may consider the effort as overwhelming as the disease itself.


Now, a long-term weight loss study has demonstrated that even modest reductions in weight contribute to improved quality of life. The participants, who were all mildly obese, were generally in their late 50s or early 60s, female and white. The improvements they made were consistent. On average, the group lost 15 pounds over 4 months of weekly meetings focused on diet, exercise and lifestyle changes. The women regained an average of 5.5 pounds the following year. Participants’ initial weight loss was associated with reduced pain levels and a quality of life comparable to that of healthy adults in the same age bracket. The decrease in pain motivated participants to maintain their weight loss.


“For someone who is very overweight, as little as a 15-pound weight loss over 16 weeks can result in decreased discomfort, increased quality of life, and motivation for staying active and healthy,” said Steffany Haaz, project director at the Johns Hopkins Arthritis Center in Baltimore, in a press release. “That means just 1 pound a week translates into significant improvements in comfort and movement.”

Obesity Hurts Kids' Feet

If you work with obese children, you may need to become more aware of how their condition is affecting their feet. Doctors with the American College of Foot and Ankle Surgeons (ACFAS) say they’re noticing more and more overweight and obese children with foot and ankle pain. A vicious circle of foot pain and obesity may hinder some children from progressing. “You want overweight children to exercise and lose weight, but because of their weight, their feet hurt and they can’t exercise,” says Thanh Dinh, DPM, FACFAS, a foot and ankle surgeon in Boston, in a press release.

The foot is a complex structure consisting of 26 bones, 33 joints and more than 100 muscles, tendons and ligaments. Last November, researchers in Britain reported “alarming new evidence that childhood obesity changes foot structure and results in instability when walking.” Being overweight flattens the foot, straining the plantar fascia—a band of tissue that runs from the heel to the base of the toes—and causing heel pain. Because the heel bone is not fully developed until age 14 or older, overweight children are more prone to foot pain. Being overweight may also cause stress fractures (hairline breaks) in the heel bones of children.


For more information on pediatric foot and ankle conditions, visit www.footphysicians.com.

Flex And Relax

Are you interested in exploring moves but not ready to teach an entire class of them? Cool-downs are a great opportunity to introduce mindful exercises to students. The following movements will increase flexibility and help students feel relaxed as they head back into the “real world” outside the group exercise room.

Connection Transition

The cool-down slowly brings heart rates down to preclass resting rates as participants make the transition from the class’s core (the most intense work, whether it be cardiovascular or strength) to its finish. Aim to link breath with movement, making a true mind-body connection.

Mountain Pose. Stand with big toes together, heels slightly apart.
Transition: Step out to plié squat.

Sun God. At top of plié squat, move arms up, palms touching, and look up.

Moon God. While still in plié, pull arms down, elbows bent, and squeeze shoulder blades down and back, arms at a 90-degree angle.

Repeat sun god/moon god series (4x); hold at bottom of plié squat.

Side-Bend Stretch (Right [R] Side). Place R hand or elbow on thigh; stretch left (L) arm up and over to R side, chest open. Look up toward ceiling, and reach to R side again. Return to center, and lower arm.

Repeat sun god/moon god series (4x); hold at bottom of plié squat.

Repeat side-bend stretch, L side.

Transition: Step feet back together, and lower arms to mountain pose.

Fan (Chest Opener) and Plank. Clasp hands behind back; inhale and lift chest; exhale and fold forward as arms stretch toward ceiling. Hold for 2–4 breaths. Release hands to shins or floor. Bend knees, and step back to plank position (top of triceps push-up).

Chaturanga. Lower to triceps push-up position; hold, without letting hips or belly touch the mat. Modification: Lower knees to floor.

Upward-Facing Dog. Roll onto tops of feet, extend spine, lift chest, draw shoulders down and away from ears, and push away from floor. Hips remain lifted off mat. Modification: Lower knees to floor.

Downward-Facing Dog. Lift hips up and back until body is an inverted “V,” tailbone to ceiling. Lengthen legs, press heels into mat, and line ears between shoulders.

Crouching Downward-Facing Dog. Bend knees, move hips to back wall, and extend R leg. Rotate hips R, squaring shoulders to floor.

Repeat on L side.

Repeat crouching downward-facing dog series, alternating sides (4x). On last pair, hold leg up for 2–4 breaths, open hips, and square shoulders to floor.

Transition to pigeon pose by slowly bending R knee and bringing it between arms. Hold for 4 breaths. Lift hips up and step back into plank.

Repeat chaturanga, upward-facing dog and downward-facing dog.

Repeat crouching downward-facing dog series, starting with L lead and alternating sides (4x). On last pair, hold leg up for 2–4 breaths, open hips, and square shoulders toward floor.

Transition to pigeon pose (L side) and hold for 4 breaths. Lift hips up and step back into plank.

Cat/Cow. Lower to hands and knees, move into cat/cow stretch series (4x). Bend knees, and sit back in child’s pose. Lower to elbows; push up into hands-and-knees position. Repeat cat/cow series.

Transition: Sit on one hip and swing legs around slowly to front of mat for butterfly stretch.

Relaxation. Do a series of deep breathing exercises and finish in corpse pose. Lead the class to a calm and peaceful ending with a guided relaxation.

Screening With Meaning

Group fitness instructors are key players in building a successful fitness center. They touch more members in 60 minutes or less than any of your other staff. This quality time can set a strong foundation for program growth, increased revenue, new-member attraction and, most important, member retention. When you consider an instructor’s impact on member experience, the need for a comprehensive hiring process comes into full focus.

As the fitness industry grows, the pool of well-trained instructors does not appear to be keeping pace. This imbalance means that club owners and managers are faced with a greater demand for classes, but fewer teachers to cover them. Shortages often lead to desperate hiring practices—awarding pivotal positions to candidates without fully screening for qualifications and talents. But the importance of thorough screening should never be underestimated. Linda Hendrickson, group fitness director at Healthtrax Fitness & Wellness in Avon, Connecticut, encourages her fellow directors to interview and audition everyone. “Be prepared! You never know when your schedule may change and you must have an instructor ready and waiting in the wings.”


Many factors go into hiring a group fitness instructor. A friendly smile, a chipper personality and an impressive resumé do not always mean a perfect fit for your facility. Fortune 500 companies are successful in part because of rigid hiring processes. A company may set up several levels of interviews to ensure that potential hires have characteristics that will not only benefit customers but also strengthen internal work teams.

Take the time to screen applicants in various scenarios. This will help you determine whether each candidate will be a boon to your program. A meticulous, step-by-step approach allows you to view the many facets of an individual in action. Such care also speaks volumes about your facility, as it shows both members and other fitness professionals that you have set the bar high for providing excellent service. A thorough hiring process for group exercise includes a personal interview, a movement analysis and auditions. Yes, that’s right . . . auditions, plural.

The Personal Interview

Conducting a personal interview with a prospective instructor is the first step in the hiring process. As a director, this allows you to get more familiar with candidates. Set up face-to-face, formal interviews. Discourage lengthy phone inquiries and on-the-spot meetings. First impressions speak volumes, and it all begins with the initial interview setup and the events leading up to the question-and-answer portion of the meeting. Consider the following during this stage of the process.

Is the applicant easy to get along with or demanding of your time? This may shed light on what the person will be like to manage. If she is pushy or demanding when setting up the appointment, she may be just as demanding once hired, which could lead to a management nightmare. Also, if she is “too busy” to schedule an interview, she may be too busy to commit to a class or to sub for others.
Does the person show up for the appointment on time? The answer may indicate whether the candidate will be reliable and punctual. You want someone who is not on time, but early!

How is the applicant’s appearance? Clean and neat—it goes without saying! Look for direct eye contact, confident posture and a warm smile.

Spend at least 30 minutes interviewing and chatting. Break the ice by taking the potential instructor on a facility tour. This gives him a moment to relax before being put on the spot for questioning. Outline the center’s core values, and impart your expectations. Make questions open-ended so that you can observe the candidate’s communication skills. Dig deep, keeping in mind that you are hiring a member of a team. Probing questions might include the following:

• Why do you want to be a part of our instructor team?
• What new skills can you bring to our team?
• What are your strengths and weaknesses?
• Tell me about a great experience you had as a participant. As an instructor?
• Tell me about a negative experience you had. How did you handle it?
• Where do you see yourself in 6 months? In a year?
• How are you involved in fitness now?
• What qualities do you think a great instructor possesses? How about a poor instructor?
• What was the last continuing education course you attended? When? Why?
• What other activities are you involved in, aside from fitness?

How Do You Move?

After the personal interview, invite prospective instructors to a class taught by you or one of your lead instructors. Do a mental evaluation, and watch for anything that may indicate the quality of the aspirant’s skills, as well as her willingness to be a team player. Take note of the following characteristics:

 

Ability to Move With Ease and to the Beat of the Music (If Applicable). The instructor may not be able to perform unknown choreography flawlessly, but she should be able to move to the beat and anticipate movement and direction changes.

Facial Expressions and Body Language. Look for someone who is smiling, enjoying group exercise and having fun being a participant. A person who shows no enthusiasm while taking a class will most likely have no enthusiasm when leading a class.


Instructor Respect. Beware of the want-to-be instructor who stands on top of the lead instructor and conducts his own class by demonstrating showy moves or choreography that vary a lot from what is being taught.

Proper Form and Alignment. Participants mimic movement and do so with much less body awareness than most instructors. If the instructor has poor biomechanics, participants will perform the movements just as badly, if not worse.

Interaction With the Instructor. Look for a candidate who approaches the instructor, introduces himself and shows appreciation for a job well done. Steer clear of someone who makes no effort to interact with members or your staff, critiques the instructor or makes excuses for his own performance.

How Do You Cue?

Once you’ve found a person who can move and has the potential to be a positive addition to your team, it’s time to see what she is made of. Schedule a performance audition in which the applicant must teach a 30-minute (minimum) class to you and key staff members. Hendrickson backs up this auditioning step: “A one-on-one audition is not always effective. Allowing the person to audition in front of a group of people permits you to see the potential hire in an actual class atmosphere where you can observe skills.” A benefit to using your current team as an audience is that you can get their feedback afterward.

The audition must cover all key elements specific to the format being taught and must include warm-up, workout, cool-down and stretching sections. Focus on both positive and negative aspects of the workout so that you can offer a fair evaluation. This feedback stage may allow you to take a “diamond in the rough” and, using a little professional guidance, groom her to be one of your A-list instructors. During the audition, make note of the following key points:

Compliance With Current Group Exercise Standards and Guidelines. Be wary of exercises that were taught when headbands, thongs and leg warmers were the rage! Movements must meet current standards recommended by reputable organizations.

Exercise Modifications/Progressions. A good instructor intuitively knows how to modify moves. Note if the applicant is capable of teaching to a mixed bag of patrons.

Cuing, Phrasing and Lead Changes. Cuing in advance of movement is crucial in most group exercise classes. A good instructor has great timing and delivers cues prior to showing the moves. He is also able to begin combinations at the top of the phrasing, hitting the 8-count so the choreography flows well with the music. Tap-free choreography that offers automatic lead changes supports this seamless effect, creating a smooth and enjoyable experience for participants.


Use of Visualization. Mind-body classes are more effective if an instructor uses vivid imagery to guide clientele through uncharted territory.

Choreography Breakdown. Can the instructor reduce choreography and movement to the bare-bones minimum and then methodically build complex choreography from this base? Or does she leave the class in the dust with the hopes that they will just “get it.”

Vocal Quality. Is her voice high, squeaky and hard to hear? Does she bark out cues like a drill sergeant? Does she speak in monotone? An instructor must command attention with her voice without being abrasive. The voice should match the format and be conversational.

Where Are the Eyes? Note whether the instructor is in tune with participants or watching himself in the mirror. Does he turn around and face the class at times? A quality instructor rarely sees himself in that great big mirror. He looks beyond and into the crowd to offer modifications and motivation.

Knowledge of Basic Biomechanics and Kinesiology. Can the instructor explain the proper setup and safe execution of movements, while offering logical transitions, modifications and progressions?

Come Teach With Me!

Team-teaching offers many benefits. A team-teaching audi­tion is not necessary, but encouraged, as it allows you to assess the potential hire’s ability to interact with members. It also enables you to critique performance and extend infor­mation that will improve the applicant’s teaching skills. During this step, zero in on the instructor’s teaching and communication proficiency, not only with members, but also with the lead instructor. Be wary of an applicant who contradicts or questions the lead instructor during class. Any ambiguity should be addres­sed behind the scenes, not in front of the audience. This lack of respect may be a warning sign that the person is not a good fit for your team, regardless of her teaching ability. Darlene Challingsworth, a master instructor for FitCore™ Pilates who lives in Cranberry Township, Pennsylvania, feels that the team-teaching test should be an integral part of the hiring process. “The greatest instructor may weaken your team by not being a team player at all. You can hire the absolute best instructor [with] the ability to pack classes, yet [she may not be] supportive of the other class formats, other instructors or the club’s mission. She may use her stage time to undermine others.” Challingsworth adds that these colors often show through in a team-teaching situation. “Watch for instructors who put themselves above another instructor or, worse yet, before the members.”

Ready, Set, Teach!

You’ve filtered a prospect through many screenings. Now what? Hendrickson and Challingsworth both suggest placing your new hire on a sub list if a regular time slot is not available. “Most of my strongest instructors started as subs,” says Hendrickson. A determined instructor who truly wants to be a part of your phenomenal team will do whatever it takes to become a permanent player.

After you’ve made the decision to hire someone, revisit the team-member expectations shared in the formal interview. Make sure the instructor has a crystal-clear understanding of these expectations. Don’t presume anything. Review policies and procedures exclusive to your club, such as dress code, attendance, subbing and even emergency procedures.

Once you have assigned a permanent class to the new instructor, place him on a 90-day trial period. During this time, monitor him to ensure that members are getting the quality instruction you’ve promised them. You may want to do unannounced class visits, poll members and staff, and set aside time to communicate with the new employee one-on-one. Offer praise and support, and share any tidbits that may help him deal with members. Have an open-door policy. Being the new kid on the block can be a little challenging at times.

After 90 days, do a formal performance evaluation and follow-up interview. Revisit your team values and club mission statement, and offer advice on how to grow into a more valuable instructor. With an enthusiastic employee, entertain the idea of goal setting. This will keep you both on the same page in future reviews and evaluations.

Worth the Wait

The hiring and audition process may be long, but it provides a level of quality assurance. Most instructors will welcome this procedure, as it allows them to take the stage and showcase the skills they’ve honed over time. Don’t sell your program short by hiring a person just because she has experience or a certification. Companies wouldn’t hire someone based solely on the fact that she possessed a degree. A credential is only a base from which to grow. An extraordinary group exercise program is staffed by illustrious team players and a prudent program director. All share these common goals—to meet and exceed members’ expectations and to deliver the finest product available!

SIDEBAR: Audition Evaluation Form and Quality Checklist 

When recruiting for your group exercise team, look for an applicant who

• holds a group exercise certification from a reputable organization, plus specific certifications for specialty formats;
• is CPR and AED certified;
• has good communication skills;
• has eyes and teeth that shine;
• is comfortable in a large group;
• is energetic, enthusiastic and passionate about fitness;
• is understanding and compassionate and puts others first;
• is a team player and respects others (staff and members);
• is confident;
• shows loyalty and commitment to team and club;
• is able to educate and motivate; and
• is eager to learn new things.

Heart Disease: Is There a Gender Divide?

How fitness professionals can educate their female clients about the benefits of heart health and preventive care.

Although many women worry about their risk of getting breast cancer, heart disease is actually the leading killer of females in America. Not only does heart disease kill more women than men each year (Thom et al. 2006), but females who survive a cardiac event fare much worse than their male counterparts (Blomkalns et al. 2005). Yet many women and their physicians fail to recognize the toll that cardiovascular disease (CVD) can take on the female body, and thus fail to do what is necessary to reduce the risk of getting this largely preventable disease (Mosca et al. 2005).

Now the latest research and recommendations are in: lifestyle modification is crucial (in fact, it trumps medical intervention) when it comes to preventing CVD in women. The American Heart Association’s (AHA) Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women was updated and released this year (Mosca et al. 2007). These new guidelines present a major opportunity for fitness professionals to help women greatly reduce their risk of developing CVD.

This article provides a primer on how CVD develops in women; how the condition differs in women as opposed to men; how to recognize the risk factors and signs and symptoms in women; and how to understand and apply the latest recommendations and lifestyle modifications that will benefit your female clients. Further, it will provide practical tips and recommendations to empower fitness professionals to take action within their scope of practice.

What Is CVD?

The term cardiovascular disease refers to any disease of the heart and its blood vessels. Generally speaking, CVD is an umbrella term that encompasses all conditions affecting the heart muscle itself, the valves of the heart and/or the blood vessels that supply the heart (i.e., coronary arteries).

Vessel disease, or vascular disease, includes diseases such as hypertension (high blood pressure) and atherosclerosis (hardening of the arteries caused by the formation of plaque deposits within the arterial wall).

Heart disease is a complicated subject that exceeds the scope of this article; for a more thorough description of the different types of CVD, check out www.mayoclinic.com/health/cardiovascular-disease/HB00032.

How Does CVD Develop?

Atherosclerosis of the coronary arteries is the main culprit behind chest pain (angina) and heart attack (myocardial infarction). Although the condition is not usually dangerous until middle age and beyond, atherosclerosis typically begins to develop in childhood (Haust 1990; McMahan et al. 2006).

During the earliest stages of atherosclerosis, “fatty streaks” of oxidized cholesterol and lipid particles accumulate deep in the arterial wall. Due to the typical high-fat, low-fiber diet and sedentary lifestyle favored by the majority of Americans, the fatty streaks develop by the teenage years (McGill & McMahan 1998). Because these fatty streaks do not yet obstruct blood flow, there are no outward signs or symptoms of CVD.

Over time, however, a cholesterol plaque develops in the artery, which may become susceptible to rupture. This fibrous plaque tends to form in males by their 20s and in females by their 50s–60s. An advanced lesion, or complicated plaque, develops as the fibrous plaque continues to progress and becomes calcified. Males tend to develop lesions by age 30–40, whereas this occurs in females much later in life, usually by age 70. Often, the first sign of CVD in both men and women is a heart attack in which a lesion ruptures, forming a clot in the artery that completely obstructs blood flow (Fuster et al. 2005).

High blood cholesterol levels, particularly low-density lipoprotein (LDL) levels, coupled with oxidation of that cholesterol, are the main culprits in the development of atherosclerosis.

How Is CVD Different in Women Than in Men?

So why do women have a slower progression of artery-clogging plaques, but a higher total morbidity and mortality rate than men, even though a smaller percentage of women are affected by the disease (AHA 2007)? Women develop heart disease about 10–15 years later than men due to high levels of estrogen. Estrogen produced by the body is thought to help protect the heart because the hormone

• lowers dangerous LDL cholesterol levels;
• increases healthy high-density (HDL) cholesterol levels;
• reduces the progression of lesions; and
• dissolves clots (Klouche 2006).

After menopause, the levels of estrogen in a woman’s body drop, which increases the risk of CVD (Rosano et al. 2007). That’s partly why older age is considered a risk factor for heart disease in women after age 55, compared with age 45 for men. However, it is important to note that taking estrogen supplements does not protect the heart and might increase the risk of other serious conditions, such as breast cancer, stroke and blood clots (Manson et al. 2003; United States Preventive Services Task Force [USPSTF] 2005).

Even if women do get heart disease later in life than men, that doesn’t explain why they have worse outcomes and die more often from the disease than men do. While the reason for this disparity is still unknown, it may be partly because women tend to be older when they have a first heart attack and are thus more likely to die from it in the first few weeks following the event. But even this theory doesn’t account for all of the difference between outcomes and mortality rates. Some of the disparity may lie in how women are treated by the medical community.

Educating Women & Physicians About the Differences

Sad to say, but many physicians and women suffer from a lack of knowledge about the serious threat that CVD poses to females.

“Heart disease should top the list of women’s health concerns; unfortunately, it doesn’t even come close,” according to Sharonne Hayes, MD, director of the Mayo Clinic Women’s Heart Clinic at Mayo Clinic College of Medicine in Rochester, Minnesota. “Many women have a disproportionate fear of breast cancer and dutifully present for annual mammography while remaining oblivious to their risk of cardiovascular disease” (Hayes 2006).

This is borne out by the fact that only 57% of women in 2006 knew that CVD disease is the number-one killer for women, according to statistics provided by the National Heart, Lung, and Blood Institute (NHLBI 2007). Although that is an improvement from the 34% who were aware of this fact in 2000, it still isn’t nearly enough (NHLBI 2007).

When it comes to the medical community, many doctors themselves need some educating. Fewer than 1 in 5 physicians in 2004 knew that more women than men die of CVD each year (Mosca et al. 2005). Beyond a knowledge deficit, physicians also consistently perceive that there is a lower risk for CVD in women compared with men (Mosca et al. 2005).

Complicating this misunderstanding, many women and doctors also fail to recognize the early signs of an impending cardiovascular catastrophe. Unlike men, women often don’t experience the “typical” signs of heart disease, such as chest pain. When women patients do complain of chest discomfort, they often fail to describe it as pain in the chest, instead reporting an aching, tightness or pressure in the area. More often, women experience different symptoms than men—sometimes 4–6 months or more—before an actual heart attack or other cardiovascular event. These symptoms could include severe fatigue, sleep disturbances, shortness of breath, indigestion and anxiety (McSweeney et al. 2003). This disparity in signs and symptoms and terminology is important because physicians and emergency room personnel often assess primarily for chest pain when trying to rule out or rule in a heart attack.

Even when medical personnel do recognize that a woman might be experiencing CVD, their female patients often don’t get the treatment that they need. Women typically receive fewer cardiac procedures, such as catheterization and bypass surgery (Seils, Friedman & Schulman 2001); thrombolytic therapy to destroy blood clots (Grace et al. 2003); cardiac rehabilitation (Witt et al. 2004) or even prescriptions for drugs to treat CVD (Harrold et al. 2003).

Studies show that women also have worse in-hospital and long-term outcomes and increased hospital readmission following bypass surgery, unrelated to patient characteristics, such as presurgery health status or illness severity (Vaccarino et al. 2003). Many of these harmful outcomes can be improved or even prevented with increased research, awareness, advocacy and vigorous attempts at lifestyle change. Fitness professionals in particular are uniquely positioned to inspire such change in their female clients.

Educate Clients About Their Risk

As a fitness professional, you are committed to helping people to adopt healthier lifestyles. With your health and science knowledge, you also serve a critical role as a link between the lay consumer and the busy, time-constrained physician who often fails to provide crucial lifestyle recommendations (Mosca et al. 2005).

Empower your female clients of all ages to minimize their CVD risk by educating them about the known risk factors and encouraging them to talk with their doctor about their own personal risk.

Some risk factors for CVD include

• elevated total and LDL cholesterol levels
• low HDL cholesterol levels
• obesity
• smoking
• hypertension
• sedentary lifestyle
• poor diet
• stress
• depression
• family history of premature CVD
• middle age
• diabetes (National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults 2002; Mosca et al. 2007)

The more risk factors that are present, the higher the risk of atherosclerosis and subsequent heart attack or stroke. A simple preventive health check-up at the doctor’s office and a blood draw in the lab can arm a woman with the information needed to determine her specific risk. Give your clients a copy of “Questions to Ask Your Doctor,” below, to bring to their appointments.

Emphasize to clients the importance of closely monitoring the development of any of these risk factors. This is vital not only for older female clients who may have already developed one or more risk factors and now must vigorously work to reverse them or at least prevent their progression, but also to your younger clients who seem to be perfectly healthy.

“There appears to be a critical period in young adulthood to middle age, where if you avoid getting risk factors, you can almost abolish your risk of getting heart disease,” says Donald M. Lloyd-Jones, MD, associate professor of preventive medicine at Northwestern University’s Feinberg School of Medicine in Chicago, in an article that appeared in a recent issue of the Journal of the American Medical Association (Mitka 2007). “And while eliminating risk factors once they are present through lifestyle modification or medical therapy reduces your chances of getting heart disease, it doesn’t come anywhere close to the protection you have if you’ve never had the risk factors.”

Lloyd-Jones should know. He is the lead author of a study that found if you can make it to age 50 without experiencing these risk factors, your chance of developing heart disease is very low; only 8.2% of women with no risk factors developed CVD, compared to 50.2% of women who had 2 or more risk factors (Lloyd-Jones 2006). These results prove that it’s never too early to start your heart disease prevention lifestyle change.

Encourage Clients to Take Action

After your client visits her physician, ask if the doctor determined her risk stratification. The 2007 AHA guidelines encourage all women to be stratified as either “optimal risk,” “at risk” or “high risk” based on their risk factors (Mosca et al. 2007). This risk stratification helps determine the intensity of medication and lifestyle treatments necessary to lessen the odds of a future heart attack or cardiovascular-related death. See sidebar “How to Estimate Your Risk,” below, to view the tool physicians utilize to assess risk and determine CVD management.

If your client is determined to be at “high risk,” that means she has a greater than 20% chance of having a heart attack in the next 10 years (Mosca et al. 2007). People with pre-existing CVD and/or diabetes are automatically considered high risk. Clients who are at high risk are most in need of some serious and sweeping lifestyle modifications.

An “at risk” client has one or more risk factors for heart disease. While the chances are low that she will have a cardiovascular event in the next 10 years, her lifetime risk of heart disease is high, and she should initiate efforts to decrease the odds (Mosca et al. 2007).

“Optimal risk” means that a client has less than a 10% chance of experiencing a heart attack or coronary death in the next 10 years, based on the Framingham risk assessment tool (Mosca et al. 2007). While this sounds less dire than the other stratifications, it doesn’t mean she should pat herself on the back and treat the whole family to pepperoni pizza for dinner on a nightly basis. Rather, her goal should be to remain free of risk factors to age 50 and beyond so that she can drastically minimize her risk of ever developing CVD.

Recommend These Strategies

Regardless of risk stratification, all clients should be encouraged to follow these guidelines, with women at highest risk needing to make changes urgently:
Quit Smoking. Smoking is responsible for multiple serious diseases. A lean and physically fit, fruit-and vegetable-loving woman who smokes is not healthy and is not immune from CVD.

Aim for a Healthy Body Mass Index (BMI). A BMI of between 18.5 and 24.9 is considered optimal (check out www.nhlbisupport.com/bmi/ to determine your BMI). While this BMI range may be out of the question for many clients, even a 5%–10% weight loss reduces CVD disease risk (Tuomilehto et al. 2001).

Engage in Regular Exercise. Experts recommend getting at least 30 minutes of moderate-intensity physical activity daily. If your client needs to lose weight, up that time to 60–90 minutes daily. Help your clients plan ways to incorporate enjoyable and invigorating physical activities into their daily routine. Remind them that a simple brisk walk with their dog or with a friend after dinner counts.


Participate in a Cardiac Rehabilitation Program. This program can be in-hospital or a physician-guided home- or community-based exercise training program. Clients who have had a recent acute coronary syndrome or coronary intervention, new-onset or chronic chest pain, recent stroke, peripheral vascular disease or symptoms of heart failure need cardiac rehab to prevent a future event.

Eat a Healthy Diet. Aim for a regular diet rich in fruits and vegetables, whole grains and high-fiber foods. Consume fish (in particular oily fish like salmon, trout and tuna) at least twice per week; limit saturated fat, cholesterol, alcohol and sodium intake. Avoid any foods that contain trans fats. Advise clients to check out the MyPyramid website (www.mypyramid.gov), which offers many resources to help people get started. If more help is needed, refer your clients to a registered dietitian.

Seek Help for Depression. Depression wreaks havoc on the heart and arteries. If your client has depression that doesn’t improve with a regular exercise program, strongly encourage her to seek professional help not only for her mental health, but also to protect her heart.

While all of these strategies may sound fairly straightforward, keep in mind that only 3% of Americans eat healthfully, engage in regular physical activity, maintain a healthy weight and don’t smoke (Sandmaier 2007). That leaves a lot of room for fitness professionals to make a difference. For more tips, see “10 Ways to Educate Female Clients About CVD” below.

A Final Call to Action

Heart disease robs women of their quality of life and can be deadly. The clock is ticking for all women—regardless of age, risk factor status, race or socioeconomic status—to take action. As a fitness professional, you can inspire women around the world to embrace fitness, wholesome nutrition and a healthy heart.

SIDEBAR: Questions to Ask Your Doctor

Encourage your clients to take this list to their physician’s office; the answers to these questions will provide vital information needed to optimize heart health.

• What is my risk for heart disease?
• What is my blood pressure reading? What does this reading mean for me, and what do I need to do about it?
• What are my cholesterol numbers? These should include total cholesterol, LDL (or “bad”) cholesterol, HDL (or “good”) cholesterol and triglycerides. What do these numbers mean for me, and what do I need to do about them?
• What is my body mass index (BMI) and my waist circumference measurement? Do these numbers indicate that I need to lose weight?
• What is my blood sugar level? Does it mean that I’m at risk for diabetes?
• What other screening tests for heart disease do I need? How often should I return for checkups for my heart health?
• What tools can I employ to quit smoking?
• How much physical activity do I need to help protect my heart?
• What is a heart healthy eating plan for me? Should I see a registered dietitian to learn more about healthy eating?
• How can I tell if I’m having a heart attack? What are the typical signs in a woman compared with a man?

SIDEBAR: How to Estimate Your Risk

SIDEBAR: 10 Ways to Educate Female Clients About CVD

Share these strategies with your female clients to help increase awareness of their risk of developing cardiovascular disease:

1. Get the Word Out to Clients. Go to the Heart Truth website (www.hearttruth.gov) and order your red dress pin, which is used to educate the public about the toll that heart disease takes on women. Then wear your pin to work, and tell everyone who asks (and even some who don’t) what it signifies. This can lead to a discussion of other ways to reduce the risk of CVD.
2. Provide Clients With Pamphlets on Heart Health. Order several copies of the “Healthy Heart Handbook for Women” from the hearttruth.gov website, and display them prominently in your facility. You might put a few copies in the magazine rack by your cardio machines, in the locker room or at the front desk near the fitness class schedule.
3. Offer Free Risk Factor Screening at Your Facility. Measure fasting lipoprotein profile, blood pressure, fasting blood glucose, waist circumference and BMI. Make sure you tell participants what these numbers mean and how they can take action to decrease their risk.
4. Encourage Clients to See Their Doctor for a Risk Factor Assessment. Ask them to bring you their results so you can help them stick to a plan. You can also use the results to modify their exercise program to further help reduce their risk. When speaking to their physician, remind clients to speak up and ask questions about their risk of developing heart disease and ways to reduce that risk.
5. Offer an Educational Seminar on Women and Heart Disease. The website hearttruth.gov offers a speaker’s kit that provides all the materials and information you will need.
6. Communicate With Your Clients’ Other Healthcare Providers. With your client’s permission, ask her doctor for a risk factor assessment and recommendations and contraindications for an exercise program. On a quarterly basis, fax the physician quarterly progress reports that show the client’s progress and fitness level. This communication will prompt the doctor to ask the client about improvements in physical activity and weight loss and will also make it more likely that the physician will closely monitor the woman’s CVD risk factor status.
7. Wear Red to Show Your Support. National Wear Red Day is February 1, 2008. You can make this event a day of recognition and education at your club. The American Heart Association campaign called National Go Red for Women has developed a list of materials that you will need; access this list at www.goredforwomen.org.
8. Become a Volunteer Advocate for Heart Health. Offer your services and expertise pro bono to women in your community who may be at risk for heart disease but cannot afford to join a health club.
9. Walk the Walk. Be a good role model and learn about your own personal risk of heart disease. Educate your own mom, wife, sister, daughters, neighbors, coworkers and all female clients about heart health, and work vigorously to change modifiable risk factors.
10. Continue Doing What You Do Best. Your efforts to help your clients develop a safe, enjoyable and effective exercise program is critically important to help them reduce their risk of CVD. Know that your work is incredibly important, and continue your tireless efforts to help women adopt an active and healthier lifestyle.

SIDEBAR: Additional Resources for Women?

• The National Heart, Lung, and Blood Institute’s (NHLBI) The Heart Truth (www.hearttruth.gov). This national awareness campaign informs women about the risk of heart disease. The website includes a link to the “Healthy Heart Handbook for Women” for download or purchase ($4). The handbook provides a comprehensive update of the latest knowledge of women and heart disease as well as practical tips to reduce risk.
• The NHLBI “Your Guide to Better Health” (http://hp2010.nhlbihin
• .net/yourguide). This series includes a guide on living with heart disease, lowering blood pressure through diet; lowering cholesterol levels; and increasing physical activity.
• American Heart Association (www.americanheart.org). The AHA is the leading organization devoted to the prevention and treatment of heart disease; this website provides myriad resources and opportunities to improve heart health.
• Society for Women’s Health Research (www.womenshealth research.org). Check out the comprehensive statistics on gender differences in cardiovascular disease.
• WomenHeart. The National Coalition for Women with Heart Disease (www.womenheart.org) is a patient advocacy organization devoted to providing resources and support to women with heart disease.
• Heart Healthy Women (www.hearthealthywomen.org). This highly reputable online source provides educational resource for patients and healthcare providers.
• Sister to Sister Foundation (www.sistertosister.org). This nonprofit organization is dedicated to prevent heart disease in women; the organization provides free cardiovascular screening and education.

Natalie Digate Muth, MPH, RD, CSCS, is a registered dietitian and medical student at the University of North Carolina, Chapel Hill. As part of her training, she is currently conducting research on cholesterol and CVD risk at the University of California, San Diego. She is also a master trainer for the American Council on Exercise.

Activity Level Predicts Heart Disease in Women

New research suggests that a woman’s level of physical activity is a better sign than body weight of existing coronary artery disease and future heart problems. The study, which appeared in the September 8 issue of the Journal of the American Medical Association (2004; 292 [10], 1179–87), examined 906 women who had chest pain, suspected narrowing of the coronary arteries, or both. Researchers calculated each woman’s body mass index (BMI), and patients were categorized as normal weight, overweight or obese. In addition, the women answered a questionnaire that assessed their physical activity levels and abilities.


In all, 76% of the participants were classified as overweight and 41% of those as obese. Low physical activity levels were reported by 70% of the women. The researchers detected no difference in the presence or severity of disease for women in different weight categories. However, a significant association emerged between low physical activity level and the existence of obstructive coronary artery disease.


Researchers concluded that low physical activity was a good indicator of future heart problems. Women who were at least moderately active had a lower risk of adverse cardiovascular events than women with a low physical activity level, no matter which weight category they were in.